CurrentEmblemHealthPolicy MG.MMPH.1SO
Imlygicc (talimogene laherparepvec) Intralesional
Defines EmblemHealth medical necessity criteria, dosing, limitations, authorization length, applicable codes and ICD-10 diagnoses for intralesional talimogene laherparepvec (Imlygic) for cutaneous melanoma. Includes initial and renewal criteria, exclusions, dosing/administration, maximum units, and billing codes/NDCs.
Policy Summary
PayerEmblemHealth
PolicyImlygicc (talimogene laherparepvec) Intralesional
Policy CodePolicy MG.MMPH.1SO
Change TypeICD-10 updates; prior 2024 initial criteria revision
Effective DateApr 1, 2025
Next Review Date
Key ActionTreating physician must submit clinical evidence that the member meets the criteria for treatment to EmblemHealth (preauthorization or post-payment review).
SourceLink
POLICY UPDATE CHANGES
April 1, 2025 annual review: Updated ICD-10 codes. No criteria changes.
02/16/2024 changes: Initial criteria language revised and name changed to 'Cutaneous Melanoma'.
6Length of initial authorization (months)
4 mLMax volume per intralesional injection
J9325Primary billing CPT/HCPCS code
2Dose schedule interval (weeks)